Rev. Bras. Reumatol. vol.56 número6

(1)

rev bras reumatol.2016;56(6):530–542

ww w . r e u m a t o l o g i a . c o m . b r

REVISTA

BRASILEIRA

DE

REUMATOLOGIA

Review

article

Effects

of

aquatic

exercise

on

muscle

strength

and

functional

performance

of

individuals

with

osteoarthritis:

a

systematic

review

Fernanda

de

Mattos

a,∗

,

Neiva

Leite

a

,

Arthur

Pitta

b

,

Paulo

Cesar

Barauce

Bento

a

a_Universidade_Federal_do_Paraná_(UFPR),_Curitiba,_PR,_Brazil

b_Universidade_Federal_do_Paraná_(UFPR),_Departamento_de_Educação_Física,_Programa_de_{Pós-graduação}_em_Educação_Física,_Curitiba,

PR,Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received27October2015

Accepted15June2016

Availableonline4October2016

Keywords: Osteoarthritis

Water-basedexercise

Physicalfunction

Musclestrength

a

b

s

t

r

a

c

t

Water-basedexercises arerecommendedforpeoplewithosteoarthritis(OA), duetothe

beneficialeffectsonphysicalfunction,qualityoflifeandsymptomreduction.However,the

effectsonmusclestrengtharestillcontroversial.Theaimofthisreviewwastoassessand

comparetheeffectsofaquaticexerciseprogramsonmusclestrengthandphysicalfunction

inpeoplewithOA.AsystematicsearchwasperformedatPubmed,ScopusandWebof

Sci-encedatabases.Clinicaltrialswithinterventionsinvolvingaquaticexercisesforindividuals

withOAwereincluded.Themethodologicalqualityofthestudieswasevaluatedusingthe

PEDroscale.296studieswerefoundandtwelvewereselected:sixstudiescomparing

water-basedexerciseswithland-basedexercise,andsixcomparingwater-basedexercisegroups

withthecontrolgroup.Exerciseprogramsincludedmusclestrengthening,aerobic,balance,

flexibilityandstretchingexercises.Durationoftheprogram,weeklyfrequency,intensity

andprogressionvariedbetweenstudies.Beneficialeffectsofaquaticexercisewerefoundon

physicalfunction.However,onlytwooffivestudiesthatassessedmusclestrengthobserved

positiveeffectofaquaticexercise.Althoughitisdifficulttocomparestudiesandestablish

guidelinesforthestandardizedprotocolformulation,itwasobservedthatwater-based

exer-cisescanbeeffectiveonimprovingphysicalfunctionandincreasingmusclestrength,since

theyarewell-structured,withexerciseintensityandoverloadcontrolled.

license(http://creativecommons.org/licenses/by-nc-nd/4.0/).

∗ _{Corresponding}_author.

E-mail:[email protected](F.Mattos).

http://dx.doi.org/10.1016/j.rbre.2016.09.003

(2)

531 Efeitos

do

exercício

aquático

na

forc¸a

muscular

e

no

desempenho

funcional

de

indivíduos

com

osteoartrite:

uma

revisão

sistemática

Palavras-chave: Osteoartrite

Exercícioaquático

Funcionalidade

Forc¸amuscular

r

e

s

u

m

o

Exercíciosaquáticossãorecomendadosparapessoascomosteoartrite(OA),pois

melho-ramafuncionalidade,aqualidadedevidaereduzemossintomasdadoenc¸a.Entretanto,

osefeitosnaforc¸amuscularaindasãocontroversos.Oobjetivodestarevisãofoiavaliare

compararoefeitodeprogramasdeexercíciosaquáticosnaforc¸amuscularena

funcionali-dadedepessoascomOA.FoirealizadaumabuscabibliográficanasbasesdedadosPubmed,

ScopuseWebofScience.Foramincluídosensaiosclínicosrealizadoscomintervenc¸ões

envolvendoexercíciosaquáticosparaindivíduoscomOA.Aqualidademetodológicados

estudosfoiavaliadapormeiodaescalaPEDro.Foramencontrados296estudosnototal.

Destes,dozeforamselecionados,sendoseisestudosquecompararamexercíciosaquáticos

comexercíciosrealizadosemsolo,eseisquecompararamumgrupodeexercíciosaquáticos

comgrupocontrole.Osprogramascontemplaramexercíciosdefortalecimentomuscular,

aeróbios,deequilíbrio,deflexibilidadeealongamento.Adurac¸ãodoprograma,afrequência

semanal,aintensidadeeaprogressãovariaramentreosestudos.Foramencontradosefeitos

benéficosdoexercícioaquáticonafuncionalidade,porém,doscincoestudosqueavaliaram

aforc¸amuscular,apenasdoisverificaramefeitopositivodosexercíciosaquáticos.

Emb-orahajadificuldadesparacompararosestudoseestabelecerdiretrizesparaaformulac¸ão

deprotocolospadronizados,observou-sequeexercíciosaquáticospodemsereficientesna

melhoradafuncionalidadeenoaumentodaforc¸amuscular,desdequeosprogramassejam

bemestruturadoscomintensidadeesobrecargacontroladaeprogressiva.

BY-NC-ND(http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Osteoarthritis(OA)isachronicdegenerativediseaseof

mul-tifactorialorigin,beginningusuallybetween50and60years

ofage,1_primarily_affecting_knee_and_hip_joints.2,3_Pain_is_the

mainsymptomofthediseaseand,whenassociatedwithjoint

stiffness,instabilityandweakness,cancausefunctional

limi-tationsanddifficultiesinperformingactivitiesofdailyliving.4

The treatment of OA includes drug therapy, manual

therapy,and exercise.5,6 _Exercise_is _a_highly_recommended

conservativetreatment,witheasyapplicationandlowcost,

andwithlittlechanceofadversereactions.4_The_types_of

exer-cisesmostrecommendedforpeoplewithOAarethosecausing

alow-impactonthejoints,formusclestrengthening,aerobics,

orsomecombinationthereof,carriedoutinwateroronthe

floor.7

Thestrengtheningofthemusclesaroundtheaffectedjoint

isakeypartinthetreatmentofOA,becausethiscontributes

to the quality of cartilage, increases the neural activation

andimprovesintra-andintermuscularcoordination.8_In

addi-tion,musclesactasaload-absorbingmechanismduringthe

gait.Therefore,strongermusclescanbetterabsorband

dis-tributetheimpactonthehipandknee,whichincreasesthe

stability8–10_and_contributes_to_the_improvement_of_the

func-tionalityandmobility.11

Whencomparedtoland-basedexercises,waterexercises

canoffersomeadvantagestooverweightpatients,with

mobil-itydifficulties,sincethebody weightreliefprovidedbythe

fluctuationreducestheimpactonjointsandtheperception

ofpainintensity.12,13 _The_heated_water_and_the_hydrostatic

pressure promote muscle relaxation and stress relief, and

alsodecreasemusclespasms,13–16_which_facilitate_the

execu-tionofmovements.Inaddition,studiesinhealthyadultsand

oldersubjectshaveshownthatwaterexercisesareeffective

toincreasemusclestrength.13,17

Previouslyconductedsystematicreviewsontheeffectsof

aquaticexerciseinpeoplewithosteoarthritisfoundbenefits

forpain,functionandqualityoflife.12,13,15,18_However,_there

arenoreviewstoidentifytheeffectoftheseinterventionson

theperformanceoffunctionandmusclestrengthtests.Thus,

theaimofthisreviewwastoevaluateandcomparetheeffect

ofaquaticexerciseprogramsonmusclestrengthandonthe

functionalityofpeoplewithOA.

Methods

Todevelopthisstudy,aliteraturesearchwasperformedin

thefollowingelectronicdatabases:Pubmed,Scopus,andWeb

ofScience.Theselectionofdescriptorswasbasedonterms

indexedinDescriptorsinHealthSciences(DeCS)andincluded

the following keywords in English: osteoarthritis, aquatic,

aqua,deep-water,water-based,exercise,motoractivity,

phys-icalactivity,andtraining.Thekeywordswerecombinedusing

theBooleanoperators“AND”and“OR”,andwereadaptedfor

eachdatabase,asrequired.

Therewasnorestrictiononthepublicationyear,

consid-ering the low number of studies found in this area. Two

researchers surveyed all databases and, at the end of the

applicationofinclusionandexclusioncriteria,confrontedthe

(3)

532

Table1–Methodologicalqualityofthestudiesanalyzed.

Reference 1 2 3 4 5 6 7 8 9 10 11 Total

Wyattetal.(2001) 1 1 0 0 0 0 1 1 1 1 1 7

Wangetal.(2007) 1 1 0 1 0 0 0 1 1 1 1 7

Hinmanetal.(2007) 1 1 1 1 0 0 1 1 1 1 1 9

Silvaetal.(2008) 1 1 1 1 0 0 1 1 1 1 1 9

Lundetal.(2008) 1 1 1 1 0 0 1 1 1 1 1 9

Limetal.(2010) 1 1 1 1 0 0 1 1 1 1 1 9

ArnoldandFaulkner(2010) 1 1 1 1 0 0 1 1 1 1 1 9

Wangetal.(2011) 1 1 0 1 0 0 1 1 1 1 1 8

Haleetal.(2012) 1 1 1 1 0 0 1 1 1 1 1 9

Wallisetal.(2014) 1 0 0 1 0 0 1 1 1 1 1 7

Bresseletal.(2014) 1 0 0 1 0 0 0 1 1 1 1 6

Fiskenetal.(2015) 1 1 1 1 0 0 0 0 1 1 1 7

1,Eligibilitycriteriaspecified;2,randomizationorrandomassignment;3,secretallocation;4,similargroupsatthebeginning;5,subjectsblinded toparticipation;6,treatmentcarriedoutbyblindedresearchers;7,blindedevaluators;8,evaluationscarriedoutinatleast85%ofthesample; 9,allevaluatedsubjectsweresubmittedtotheintervention;10,resultsofthecomparisonsbetweengroupsweredescribed;11thestudyshows precisionandvariabilitymeasurementsfortheresults.

studies,theresearchersconductedapooledanalysisofstudies

withtheaimofreachingconsensus.

The following inclusion criteria were adopted: articles

publishedinEnglish,PortugueseorSpanish;onlyoriginal

arti-cles; controlledclinical trials or experimental studies with

anexperimentalgroupversus controlgroupor period;

pre-senting an intervention with supervised aquatic exercises

forpeoplewithosteoarthritis;describinginterventiondetails,

suchasduration,frequency,typeandintensity ofexercise;

withanevaluationandpresentation,asprimaryorsecondary

outcomes,ofmuscle strength and/orfunctionalitythrough

physicalperformancetests.

Conferenceabstracts,monographs,dissertationsand

the-ses,casestudies, non-controlledtrials, systematicreviews,

animalstudiesand alsostudieswithmixedgroupsof

sub-jects(osteoarthritisandotherconditionsinfluencingstrength

and/orfunctionality);interventionalstudieslastinglessthan

sixweeks,andthosewithaweeklyfrequencyoftheexercise

programundertwosessions/week,basedonreviewsof

rec-ommendationsforthetreatmentofOA,wereexcludedfrom

thisreview.4,19

The selected studies were also analyzed for

methodo-logicalquality,accordingtotheevaluationprotocoladapted

forthis study,based on the PEDroscale.20 _This _evaluation

includedelevencriteriawhich,together,generatedascoreof

11(Table1).Criteria5and6,whichdealwiththeblindingof

participantsandtherapistsregardingthetreatmentapplied,

were notscored, due tothe characteristics ofthe selected

studies.Inexperimentalstudiesincludinginterventionswith

programsofphysicalactivity,onecannotomitfrom

partici-pantsandtherapiststhetreatmentcarriedout.Therefore,the

maximumscoreachievedis9points.Thehigherthescoreon

thescale,thebetterthequalityofthestudy.

Theanalysisofthequalityofthestudieswasperformed

independentlybytworesearchers,anddisagreementswere

discussedinconsensusmeetings.Methodologicalqualitywas

assessed with the aim of identifying the internal validity

(criteria2–9)andthequalityofstatisticalinformationforthe

interpretationofresults(criteria10–11).20_After_this_step,_the

outcomesassessedandtheresultsofthestudieswere

ana-lyzedandgroupedintotopics,forcomparisonanddiscussion.

Results

In theelectronicsearch conducted,296studies inallthree

databaseswerefound.Aftertheexclusionofrepeatedtitles,

170 articles remained foranalysis. Afterthe applicationof

inclusionandexclusioncriteria,83titleswereexcluded.Inthe

abstractanalysisstage,48articlesand8systematicreviews

wereexcluded,sincethesestudiesdidnotmeettheobjectives

ofthisreview.Ofthe31remainingarticlesforafullreading,

12wereincludedinthisreview:eightrandomizedcontrolled

trialsandfourexperimentalstudies(Fig.1).

Methodologicalquality

Thescoringoftheselectedstudiesintheevaluationoftheir

methodologicalqualityisdescribedinTable1.Themeanscore

ofthestudieswas8(6–9)points.Themaximumscore(9points)

wasascribedtosixofthe12studiesassessed.14,21–25_Four

crite-riawerecoveredbyallstudiesselected:“eligibilitycriteria”;

“allevaluatedsubjectsreceivedintervention”;“resultsofthe

comparisonsbetweengroups”;and“precisionandvariability

measurements.”Innineofthe12studies,theevaluatorswere

unaware ofthe groupinwhich participantswere allocated

(single-blinded).14,21–28_Only_those_studies_which_used_a_single

groupwithadoublepre-test(withafour-weekcontrolperiod)

hadnotarandomallocationofparticipants.28,29

Characteristicsofstudies

The characteristics ofthe studies (participants, measuring

instruments, interventions, and main results) are

summa-rized inTable2.However,thesefeaturesarepresentedand

groupedinthefollowingtext.

Locationandcharacteristicsoftheparticipants

The selected studies were performed in the United

States,26,29,30 _Australia,14,28 _Brazil,25 _Denmark,24 _Korea,23

Canada,21 _Taiwan,27 _and _New _Zealand.22,31 _The _study

par-ticipants were recruited from Orthopedic Clinics in local

(4)

533

PubMed=71 Scopus=109 Web of science=116

Total=296

Evaluation by title

Excluded (n=126) 126 repeated Evaluation by summary

(n=170)

Full-text reading (n=27)

Studies included in the systematic review

(n=12)

9 Korean language

2 mixed group with osteoarthritis and rheumatoid arthritis

1 less than 6 weeks of intervention 1 summary of a monograph

1 intervention less than 2 times per week 1 Insufficient data intervention

Excluded (n=15) 43 revisions

100 did not meet the objectives of this study Excluded (n=143)

Fig.1–Schematicrepresentationoftheselectionofthestudiesincludedinthisreview.

clinics,14,21,22,24,27,29 _through _{dissemination} _in _the _local

community and in community centers.14,21,22,24,27,29–31 _All

participantshadadiagnosisofkneeand/orhipOA,14,22,28–31

onlyhipOA,21_and_only_knee_OA,23–27_were_aged_between₆₀

and75years,andmostwerefemale(72%oftotalparticipants).

Characteristicsofinterventions

Theprotocolsofexerciseprogramsdifferamongstudies,but

onecanidentifythemaincomponentsofeachprogram.Six

studies conductedinterventions with a group that

partici-patedinaquaticexerciseandanothergroupthatperformed

land-based exercise,21,23–27 _and _six _other _studies _only

con-ductedinterventionswithaquaticexercise.14,22,28–31

The programs’ duration ranged from six14,26,28,29 _to ₁₈

weeks.25 _Two _studies _conducted _8-week _{interventions,}23,24

ArnoldandFaulkner21_did₁₁_weeks_of_exercise,_and_other₄

studiesused12weeksintheirprotocol.22,27,30,31_The_weekly

frequencyofexerciseprogramsvariedfromtwo14,21,22,24,28,31

tothree23,25–27,29,30_weekly_sessions.

Aquatic exercise protocols were composed primarily of

muscle strengthening exercises for upperand lower limbs

andtrunk,14,21,28,30,31_aerobic_walking_exercises_and_shifts_in

water,14,22,28–30_and_{High-Intensity}_Training_(HIT)_in_an_aquatic

treadmill,29 _balance_disturbance_exercises,29 _one-foot_shifts

andmovements,21,22_flexibility,27,30_and_stretching.24,25

Studies comparingprograms ofwaterversusland-based

exercisessoughttofollow similarprotocols inbothmedia,

withstrengtheningexercisesofupperandlower limb

mus-cles,stretching,23–27_aerobic_walking_exercises24–27_and_water

bikeandonthefloor,23_as_detailed_in_Table₂_.

Fiveofthe12studiesusedacontrolgroupwithout

inter-vention for comparison with the groups that performed

the exercise.14,21,24,27,30 _In _studies _where_the _control_group

receivedsomekindofintervention,exerciseswereperformed

athome,23_hydrotherapy_exercises_were_performed_in

immer-sioninasittingpositioninthewater,31_and_{computer-assisted}

activities.22

Theappliedintensityalsovariedamongprotocols.Only

onestudyusedheartrateasareference,fromabasalvalue

of65%HRforaquaticexerciseand40–60%ofone-repetition

maximum(1RM)forland-basedexercise.23 _In_other_studies,

theintensitywascontrolledonthebasisofperceivedexertion

scales(0–10,BorgCR10or6–20),27,29,30_cadence_of_music,24,31

andthenumberofsetsandrepetitions.14,25_Only_two_studies

didnotcontrolordescribetheintensity,21,26_and_some

stud-iesdidnotofferin-depthinformationontheprogressionof

intensity.22,28

Outcomes

To be included in this review, the studies should

indi-cate thefunctionalityand/or musclestrength asaprimary

or secondary outcome, assessed by physical performance

tests. Only two studies pointed out functionality as a

primaryendpoint.21,31_Of_the_five_studies_that_evaluated

mus-cle strength, three presented this variable as the primary

outcome,23,24,30_and_two_as_a_secondary_outcome.14,31_Pain_was

assessedinallstudies;however,itwasconsideredasthe

pri-maryoutcomeinthreeofthem.4,24,25

Ofthe 12 studies included, only the work byLim et al.

(2010)evaluatedthefunctionalitywithoutperforming

phys-icalperformancetests.Inthisstudy,theauthors usedonly

questionnaires.Thephysicaltestsmostusedinother

stud-ies to evaluate the functionality were walking tests that

measure the distance covered in a given time in a usual

speed,14,21,27,28,30_tests_that_measure_the_time_to_cover_a_certain

distanceatdifferentspeeds,25,26,29,31_and_the_Timed_Up_and_Go

(5)

534

r

e

v

b

r

a

s

r

e

u

m

a

t

o

l

.

2

0

1

6;

5

6(6)

:530–542

Table2–Summaryofthecharacteristicsofthearticlesincludedinthereview.

Authors, year/country,type ofstudy

Sample(N),mean age(years),

numberof women,siteofOA

Groups Assessmentsoutcomes Intervention Results

Wyattetal., 2001/USA

Experimentalstudy

N=42 AG=* Initial(s0)andfinal

(s6)assessment

AG:3×wk/6wk IncreaseinROMand thighthickness,and reductionofpain andin1-miletravel timeinbothgroups 45–70yearsOAknee GG=* ROM(goniometer),

thighthickness,pain (VAS)andspeed (1-milewalktime)

Manual resis-tance+strengthening exercises

Adifference betweengroupsonly inpain;AGwith greaterreductionin pain

LLMs+244-meter walk

GG:3xwk/6wk Manualresistance exercises+LLMs++ 244-meterwalk Wangetal.2007/USA N=42 AG=20 Initial(s0),medium

(s6),andfinal(s12) assessment

AG:3×wk/50min/ 12wk

Increasedhipand kneeflexibility, musclestrengthand distancecoveredin 6minwalk

Randomizedclinical trial

66years CG=18 ROMflexibilityofknee andhip(goniometer), maximalisometric strengthofhipandknee extensionandflexion, andhipabductionand adduction(hand dynamometer),gait (6-minwalktest), functionalityandADLs (MDHAQ)andpain(VAS)

Flexibility+aerobic+ strengthening exercisesforLLMs, ULMsandtrunk (AFAPProtocol)

Nodifferencein self-reported functionandinpain betweengroups

32women Progressiveintensity

(scale0–10):s0-s4 (2–3),s5-s8(3–4),and s9–s12(4)

OAkneeandhip CG:activitiesofdaily

living

Hinmanetal. 2007/Australia Randomizedclinical trial

N=71 AG=36 Initial(s0),final(s6), andfollow-up(s12) assessment

AG:2×/45–60min/ 6wk

Hipmusclestrength andQOLimproved inAGafter6weeks. AGhada33% reductioninpain and72%ofthegroup reported

(6)

r

e

v

b

r

a

s

r

e

u

m

a

t

o

l

.

2

0

1

6;

5

6(6)

:530–542

535

Table2– (Continued₎

62years CG=35 Pain(VAS),changeinpain andfunctionality(5-point scale),osteoarthritis (WOMAC),QOL(15-item scale),physicalactivity level(PASE),isometric strengthofhipabduction andkneeextension(hand dynamometer),theStep test,TUGand6-minwalk test

Strengthening exercisesforLLMs: 2×10

reps+6–10minwalk onwater

Atfollow-up(s12) thebenefitswere maintained

48women Waterdepth

decreased throughoutthe intervention

OAkneeandhip CG:activitiesofdaily

living

Silvaetal., 2008/Brazil Randomizedclinical trial

N=64 AG=31 Initial(s0),medium

The15-mtestina comfortablespeed↓ inbothgroups,but athigh-speedGG improvedbetween s1ands9,andAG betweens9ands18A

59years GG=26 Pain(VAS),

osteoarthritis (Lequesneand WOMAC),speed (two-speed15-meter walktest)andpain duringthewalktest (VAS)andNSAIDs

Stretching:

2×20s+Strengthening exerciseforLLMs: 7–10repsof6s (isometric contractions)and 20–40reps

Pain↓inboth groups.LEQUESNE andWOMAC↓in bothgroupsuntilS9; fromS9toS18a decreaseoccurred onlyinAG

59womenOAknee Increasedresistance

totheuseofelastic orofa1-kgweight GG:3×wk/50min/ 18wk

Stretching

(7)

536

r

e

v

b

r

a

s

r

e

u

m

a

t

o

l

.

2

0

1

6;

5

6(6)

:530–542

Lundetal., 2008/Denmark Randomizedclinical trial

N=79 AG=27 Initial(s0),final(s8), andfollow-up(s20) assessment

AGandGG:2× wk/50min/8wk

Musclestrength↑inGG and↓inAGversusCG bothattheendofthe interventionandat follow-up.Theaquatic exerciseshoweda bettereffectonbalance

versusgroundexercise. Pain↓inGGversusCG infollow-up

68years GG=25 Pain(VAS),

osteoarthritis(KOOS), bodysway(static equilibrium–Balance MasterPro)and isokineticstrengthat 30,60and90◦_/s (isokinetic

dynamometer–Biodex)

Resisted

exercises+balance and

stability+stretching ofLLMs

62womenOAknee CG=27 Intensitycontrol:

music

CG:activitiesofdaily living

Limetal., 2010/Korea Randomizedclinical trial

N=75 AG=26 Initial(s0)andfinal (s8)assessment

AG:3×wk/40min/ 8wk

AGshowedimproved functionality,painand qualityoflife.Both groupsimprovedthe functionalityoflower limbs.Therewasno changeinkneeflexor andextensorstrength inbothgroups.The physicalcomponent scaleimprovedslightly inbothgroups 65years GG=25 Pain(BPI),osteoarthritis

(WOMAC),QOL(SF-36 version2.0),isokinetic strengthofknee extensorsandflexorsat 60◦_/s_(isokinetic dynamometer–Biodex)

Heating+Walk+strength+ resistance+

force−aerobic exercises

65womenOAknee CG=24 Intensity>65%ofCF

GG:3×wk/40min/ 8wk

Joint mobiliza-tion+strengthening Intensityof40–60% of1RM

CG:homeexercises: isometrics (quadriceps)and partialsquats

ArnoldandFaulkner, 2010/Canada Randomizedclinical trial

Inphysical

performance,AEGhas improvedversusCGand AG.Similartrendswere foundforTUGandfor the6-minwalktest.An improvementwas foundinefficacyoffalls inAEGversusCG 75years AEG=26 Balance(BergBalance

Scale),gait(6-min walktest),falls(ABC), functionality(STSand TUG),osteoarthritis (AIMS-2),andphysical activitylevel(PASE)

(8)

r

e

v

b

r

a

s

r

e

u

m

a

t

o

l

.

2

0

1

6;

5

6(6)

:530–542

537

Table2– (Continued)

Sample(N),mean age(years), numberof women,siteofOA

56womenOAhip CG=27

AEG:2× wk/45min/11wk Sameprogramof AG+30-min educationalsession beforewatertraining (functionaltasks) CG:activitiesofdaily living

Wangetal., 2011/Taiwan Randomizedclinical trial

N=78 AG=26 Initial(s0),medium

Significant

improvementinKOOS, ROM,6-minwalktest andpaininAGandGG

versuscontrolgroup;no significantchangewas foundbetweenAGand GG

67years GG=26 Osteoarthritis

(KOOS),ROM (goniometer)and gait(6-minwalk test)

Flexibility+aerobic exercises(AFAP protocol)

67womenOAknee CG=26 Intensity3–4(Borg

CR10Scale) GG:3×wk/60min/ 12wk

Flexibility+aerobic exercises(PACE Protocol) Intensity3–4(Borg CR10Scale) CG:activitiesofdaily living

Haleetal.,2012/New Zealand

Randomizedclinical trial

AG:2×

wk/20–60min/12wk

Inbothgroupsthere wasasignificant improvementinStep testandalso improvementintwo itemsofPPA(reaction timeandcontrast sensitivity)inCG.There wasnosignificant improvementinTUG

74years CG=16 Falls(PPAandABC),

dynamicbalance(Step Test),functionality (TUG),and

osteoarthritis(WOMAC andAIMS-2)

Heating+balance exercises↑difficulty 29womenOAknee

andhip

Waterdepth↓ throughoutthe intervention CG:2×wk/60min/ 12wk

(9)

538

r

e

v

b

r

a

s

r

e

u

m

a

t

o

l

.

2

0

1

6;

5

6(6)

:530–542

Wallisetal., 2014/Australia Experimentalstudy

N=20 AG=20 Pre(s-0),initial(s0),and final(s6)assessment

Anincreaseof12% wasfoundforthefast walktest.Therewas nosignificant improvementinSTS

71years Self-efficacy(Arthritis

Self-efficacyScale), osteoarthritis(WOMAC), gait(10-minwalktest), functionality(STS),and QOL(EQ-5DandEQ-VAS)

Educationalsessions (60min)+water exercises(45min): Functional,aerobic, ROM,strengthening exercisesofLLMsand exercisesathome (counseling) 9womenOAknee

andhip

Moderateintensity andindividual progression

Bresseletal., 2014/USASingle groupposttest, doublepretest design

N=18 AG=18 Pre-(s4),initial(s0),and final(s6)assessment

SG:2-3x

wk/18–30min/6wk

Therewas significant improvementin functionality, mobilityand balance,and reductioninknee pain

64years Osteoarthritis(KOSS),

pain(VAS),balanceand motorfunction(SMART EquiTestsystem),and functionality(STS,FLT and10-minwalktest)

Balance exercises+HIT components(aquatic mat)/waterjetsto balancedisorder

16women Intensityof14–19

overRPE OAkneeandhip

Fiskenetal., 2015/NewZealand Experimentalstudy

N=35 AG=19 Initial(s0)andfinal(s12) assessment

AG:2×

wk/45–60min/12wk

Inbothgroups,↓in timeinthe400-m walktest.AG improvedonStep testandAIMS-2.AG improvedinFES-I

versusCG.Therewas nosignificant changeinTUG,STS andgripstrengthin bothgroups 70years CG=16 Functionality(TUGandSTS),

dynamicbalance(15-secStep Test),musclestrength(hand dynamometer),gripstrength (Jamardynamometer),gait (400-mwalktest),

osteoarthritis(AIMS2-SF),falls (FES-I),physicalactivitylevel (RAPA)

Strength+aerobic exercise 23womenOAknee,

hip,spineandhands

Intensitycontrol: music

CG:1×

wk/35–40min/12wk HT-type exer-cise+hydrotherapy exercises(AFAP)wk progression

(10)

539

The evaluation of muscle strength of lower limbs was

performed by indirect tests (Chair Stand Test) in four

studies.21,28,29,31_Only_two_studies_conducted_muscle_strength

testsusinganisokineticdynamometer.23,24_Three_other

stud-ies assessed muscle strength through isometric testing of

lowerlimbswithadynamometer14,30_and_handgrip_strength

test.31

Pain is the only outcome present in all studies and

was assessed by a visual analog scale (VAS) of pain

perception,14,24–26,29,30 _or _through _{questionnaires.}21–23,27,28,31

Althoughnotaninclusioncriterioninthisstudy,theoutcome

“pain”wasaddedtotheresults,consideringthatthisfactor

waspresentinallanalyzedstudies.Additionally,painisone

ofthemostcommonsymptomsofOAandisassociatedwith

functionallimitationscausedbythedisease32,33 _and_by_the

impactofOAonthepatients’qualityoflife.34,35

Effectsofinterventions

Water×land-basedexercises

All studies comparing aquatic exercise programs and

land-basedexercisefoundsomebeneficialeffectonthe

func-tionality,forexample,anincreaseinthedistancecovered27

andadecreaseinthetimetoperformwalkingtests.25

How-ever,theaquaticexerciseprovedtobemoreefficientversus

land-basedexercisetoimprovebalanceinthestudybyLund

etal.(2008).

Theresultsofmusclestrengtharecontroversial.14,30_Only

twoofthefivestudiesthatevaluatedmusclestrengthfound

improvementafterthepracticeofaquaticexercise.Noneof

thestudiescomparingmusclestrengthbetweenthegroups

whounderwentaquaticversusland-basedexercise14,23,24,30,31

foundsomeeffectofaquaticexerciseinincreasingstrength.

Limetal.(2010)couldnotobservechangesinmusclestrength

innoneof theirgroups. However, Lundet al. (2008) found

improvement in muscle strength only in the group that

performed floor exercise, while the group that underwent

aquaticexerciseshowedadecreasedstrengthintheisokinetic

test.

Inallarticlescomparingthetwointerventions,significant

reductionswereobservedinpain,regardlessofthe

environ-mentwheretheexercisewasheld,24,25 _but_only_Wyatt_et_al.

(2001),Silvaetal.(2008)andLimetal.(2010)reportedagreater

effectinthegroupthatperformedaquaticexercises.

Waterexercises×control

Thestudiesthatcomparedagroupofaquaticexercisesand

acontrolgroupfoundbenefitsofaquaticexercise,interms

offunctionality,with physicalperformancetests. However,

Hale et al. (2012) found no difference between the group

that received the intervention with aquatic exercise and

the control group, as bothshowed improvedfunctionality.

Of the studies that performed the 30-Second Chair Stand

Test,21,28,31,36 _only _Arnold _and _Faulkner ₍₂₀₁₀₎ _found_a

sig-nificantimprovementaftertheintervention.Thegroupthat

performedaquaticexercisesandparticipatedineducational

sessionsforthepreventionoffallsincreasedby12%the

num-berofrepetitionsversustheothertwogroups.

Significanteffectsofaquaticexercisewerefoundinmuscle

strengthcomparedtothegroupwithoutinterventionintwo

studies,whichreportedanincreaseof5–10%ofthe

isomet-ricstrengthofthehipabductormuscles,14_45%_in_the_knee

extensors, 11.5%inthehipextensors, and14.3%inthehip

abductors.30_On_the_other_hand,_Fisken_et_al.₍₂₀₁₅₎_found_no

effectofaquaticexerciseintheevaluationthrough

manome-try.Painlevelsalsoshowedcontroversialresults.Threestudies

reportedreducedpainaftertheintervention.14,29,31_However,

inthestudybyFiskenetal.(2015)bothgroupshada

reduc-tion inpain, but withnodifferencebetweenthem.On the

otherhand,Wangetal.(2007)andWallisetal.(2014)found

nosignificanteffectsofaquaticexerciseinreducingpain.

Discussion

Theobjectiveofthisreviewwastoevaluateandcomparethe

effectofaquaticexerciseprogramsonmusclestrength and

functionofpeoplewithhiporkneeosteoarthritis.

Interven-tionswithexercisesthatcansloworstoptheprogressionof

thediseaseareimportanttothehealthsystem,considering

that theycan reducethe costoftreatments, surgeries,and

hospitalizations;moreover,theseinterventionscanimprove

thequalityoflifeofparticipants.12

The aquaticexercise, a procedure highly recommended

inthe treatmentofOA,may haveadvantagescomparedto

land-basedexercise,because,duetothephysicalproperties

ofwater,theexecutionofthemovementscanbecomeeasier,

decreasingalsothesensationofpain.12,13_{Strengthening}_the

musclessurroundingtheaffectedjointisanimportantpart

ofthetreatmentofOA.8–10 _Therefore, _the_resistance_of_the

waterisusedasanoverloadingfactorformuscle

strength-eningexercises.Theuseofresistivematerialspromotesan

increasedareaofcontactwithwater,andwillalsoincrease

theexerciseoverload.17,37_However,_there_is_no_consensus_yet

ontheeffectsofaquaticexerciseonmusclestrength.

In this review, only two of the five studies that

evalu-ated muscle strength showed significant effects.14,30 _Wang

etal.(2007)conducteda12-weekprogramwiththreeweekly

sessionswithastandardizedprotocolofmuscle

strengthen-ing, aerobicand flexibility exercises(AFAP protocol)38 _with

controlledandprogressiveintensity,andachievedsignificant

improvement in isometric muscle strength of knee

exten-sorsandflexorsandhipabductors,adductors,extensorsand

flexors.Similar resultswerefoundbyHinmanetal. (2007),

who prescribedtwoweeklysessionsofaquaticexercisefor

six weeks,with the progressionofthe volume and degree

ofdifficulty oftheexercises;these authorsreported

signif-icantimprovementinisometricmusclestrengthofthehip,

as assessed with hand dynamometry. The progression of

the intensityand thespecificityofexerciseare crucial

fac-tors. Both studies performed specific exercises of muscle

strengthening,whosestrengthandvolumeincreasedoverthe

program,whichmayhaveresultedinneuromuscular

adapta-tionsthroughouttheexerciseprogram.

Ontheotherhand,studiesbyLundetal.(2008),Limetal.

(2010)andFiskenetal.(2015)foundnoimprovementin

mus-clestrength.Whileonestudyreportedasignificantreduction

inmusclestrengthofkneeextensorsandflexorsinan

isoki-neticevaluationat60◦_/s_in_the_group_that_underwent_aquatic

(11)

540

(waterexercise,land-basedexercise,andcontrol)inthe

isoki-neticevaluation23 _or_in_handgrip_strength_in_the_group_that

performed aquaticexercises.31 _These _results_may _be

asso-ciatedwith the choiceof exercises,the progressionofthe

program,exerciseintensity,andtestsused.Perhapsthe

hand-gripstrengthtestdoesnotproperlyidentifystrengthgainsin

lowerlimbs.39,40

Interventionsofthesestudieshaveexaminedaquatic

exer-ciseswithoutusingresistivematerialstoincreaseoverload;

thiswasdonewiththeprogressionofthevolumeofexercise,

increasesinthenumberofrepetitions,24_or_in_the_degree_of

dif-ficultyofmovements23_and_also_in_the_speed_and_magnitude

ofimplementation of exercises31 _throughout _the _program.

Lundetal.(2008)suggestedthattherewasnoimprovement

inmusclestrengthduetothesmallresistanceimposedinthe

exercises.Theuseofmaterialsthatincreasethecontactarea

withthewaterandthepracticeofhigh-speedmovements

pro-moteanincreasedexerciseoverloadandconsequentincrease

inforceproduction.17,37,41

Additionally, Lund et al. (2008) and Fisken et al. (2015)

usedtherhythmofthemusictodetermineexerciseintensity.

Perhapsthisisnotaneffectivestrategybecauseitdoesnot

respecttheindividualityoftheparticipants.Byusingthesame

rateforallparticipants,theabsoluteeffortisthesame,butthe

relativeeffortmaydifferdependingontheparticipant’s

phys-icalfitness.InthestudyofFiskenetal.(2015),theincreasein

thespeedofexecutionofexercises,accordingtotherhythmof

themusic,wasnotenoughtopromoteimprovementin

mus-clestrength.Themusiccadenceprogressedeverytwoweeks,

rangingfrom92to162bpminthefirstfourweeks,andfrom

92to220bpmfortheremainingperiod.

Studiescomparingaquaticexerciseprogramsversus

land-basedexercises23–27 _found_similar_effects_in_both_groups_in

termsoffunctionalityandinreducingthepain;however,

land-based exerciseprogramswere more effectivein increasing

musclestrength.24_Similar_results_were_observed_in_previous

experimentalstudies4,42 _and_in_systematic_reviews.43,44 _The

land-basedexercisecanbemoreeffectiveversuswater

exer-cise,asthecontrolandincreaseinoverloadcanbeperformed

moreobjectively.

However,whenproperlyknown,thehydrodynamic

prop-ertiesofwatercanbeusedtoincreaseefficientlytheexercise

overload.45_Bento_et_al.₍₂₀₁₄₎_reported_an_increase_in_muscle

strengthinhealthyoldersubjectswhencomparinga

proto-colofaquaticversusland-basedexercises.Thestrategyused

wasthegradualincreaseintheintensityofexerciseatevery

fourweeks,increasingtheprojectedareaofthelowerlimbs

andthespeedofexecutionofmovements,whichincreases

theresistanceofferedbythewater.

TheresultsfoundbyWyattetal.(2001),Silvaetal.(2007),

Wangetal.(2007;2011),Wallisetal.(2014),Bresseletal.(2014)

andFiskenetal.(2015)forfunctionalityandmobilityindicate

thataquaticexerciseprogramslastingsixweeksormoreand

withtwotothreeweeklysessionsof45–60mincanbeeffective

inimprovingmobilityandgaitspeed.Thesimilaritybetween

themovementsperformedinaquaticexerciseanddailytasks

evaluatedinfunctionaltestscanfacilitatethetransferofthe

gainsfromtheexercise.46,47

Hinmanetal.(2007)andHaleetal.(2012)foundno

improve-ment in mobility tests, due to somecharacteristics ofthe

interventions.InthestudybyHinmanetal.(2007),thesample

wasmorephysicallyactiveandhadalowerfunctional

impair-ment,astheparticipantswereagedunder65andwithonlya

slightdegreeofinvolvementofOA,whichmayhaveinfluenced

theresults.14_Physical_exercise_promotes_more_significant

ben-efitsinolderpeoplewithgreaterfunctionalimpairment.47,48

Evenusingbalance-specificexercises,Haleetal.(2012)found

no difference between experimentaland control groupsin

terms ofbalance,duetotheinterventionperformedinthe

controlgroup.Accordingtotheseauthors,theincreaseindaily

physicalactivityandinsocialinteractionresultingfromthe

interventionwithcomputergamespromotedbenefitssimilar

tothoseintheexperimentalgroup.

Somelimitationsofthisreviewwereobserved.Thespecific

goalofthisstudyrestrictedthenumberofarticlesthatmet

theinclusionandreviewqualitycriteria.However,thestudies

foundrepresenttheliteratureonthesubject.Itwasnot

pos-sibletopoolthedatatoperformameta-analysis,duetothe

methodologicaldiversityofthestudiesandthelackofdetail

inthedescriptionofinterventions,whichalsomadeitdifficult

toidentifyastandardizedprotocolforexerciseprograms.

Conclusion

Thisreviewstudysuggeststhatwell-designedandcontrolled

interventionswithaquaticexerciselastingatleastsixweeks,

contemplating muscle strengthening exercises and aerobic

exercises, canbeeffectiveinincreasingmusclestrengthof

lower limbs and inimproving the functionalityofpatients

withOA.

Althoughthereisdifficultyincomparingdifferentexercise

programsduetomethodologicaldifferences,itseems

impor-tant anindividualizedcontrolofintensity andoverload,as

wellasoftheirprogression.However,thereisnowayto

estab-lish safeguidelines toformulate protocols. Therefore, it is

suggestedgreaterstandardization/controlandalsoagreater

levelofdetailoftheprogramsinfutureexperimentalstudies.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

r

e

f

e

r

e

n

c

e

s

1.DuarteVDS,SantosML,RodriguesKDA,RamiresJB,Arêas GPT,BorgesGF.Exercíciosfísicoseosteoartrose:umarevisão sistemática.RevistaFisioterapiaeMovimento(Curitiba). 2013;26:193–202.

2.FelsonDT,LawrenceRC.NIHConferenceOsteoarthritis:new insights.AnnInternMed.2000;133:637–9.

3.CrossM,SmithE,HoyD,NolteS,AckemanI,FransenM,etal. Theglobalburdenofhipandkneeosteoarthritis:estimates fromtheGlobalBurdenofDisease2010study.AnnRheum Dis.2014;73:1323–30.

4.BennellKL,HinmanRS.Areviewoftheclinicalevidencefor exerciseinosteoarthritisofthehipandknee.JSciMedSport. 2011;14:4–9.

(12)

541

6. McAlindonTE,BannuruRR,SullivanMC,ArdenNK, BrenbaumF,Bierma-ZeinstraSM,etal.OARSIguidelinesfor thenon-surgicalmanagementofkneeosteoarthritis. OsteoarthrCartil.2014;22:363–88.

7. NelsonAE,AllenKD,GolightlyYM,GoodeAP,JordanJM.A systematicreviewofrecommendationsandguidelinesforthe managementofosteoarthritis:TheChronicOsteoarthritis ManagementInitiativeoftheU.S.BoneandJointInitiative. SeminArthritisRheum.2014;43:701–12.

8. BeckwéeD,VaesP,CnuddeM,SwinnenE,BautmansI. Osteoarthritisoftheknee:whydoesexercisework?A qualitativestudyoftheliterature.AgeingResRev. 2013;12:226–36.

9. KnoopJ,DekkerJ,vanderLeedenM,vanderEschM, ThorstenssonCA,GerritsenM,etal.Kneejointstabilization therapyinpatientswithosteoarthritisoftheknee:a randomized,controlledtrial.OsteoarthrCartil. 2013;21:1025–34.

10.HinmanRS,HuntMA,CreabyMW,WrigleyTV,McManusFJ, BennellKL.Hipmuscleweaknessinindividualswithmedial kneeosteoarthritis.ArthritisCareRes(Hoboken).

2010;62:1190–3.

11.DeOliveiraAMI,PeccinMS,daSilvaKNG,dePaivaTeixeira LEP,TrevisaniVFM.Impactodosexercíciosnacapacidade funcionaledorempacientescomosteoartritedejoelhos: ensaioclínicorandomizado.RevBrasReumatol.

2012;52:876–82.

12.LuM,SuY,ZhangY,WangW,HeZ,LiuF,etal.Effectiveness ofaquaticexercisefortreatmentofkneeosteoarthritis: Systematicreviewandmeta-analysis.ZRheumatol. 2015;74:543–52.

13.YázigiF,EspanhaM,VieiraF,MessierSP,MonteiroC,Veloso AP.ThePICOproject:aquaticexerciseforkneeosteoarthritis inoverweightandobeseindividuals.BMCMusculoskelet Disord.2013;14:320.

14.HinmanRS,HeywoodSE,DayAR.Aquaticphysicaltherapy forhipandkneeosteoarthritis:resultsofasingle-blind randomizedcontrolledtrial.PhysTher.2007;87:32–43. 15.BarkerAL,TalevskiJ,MorelloRT,BrandCA,RahmannAE,

UrquhartDM.Effectivenessofaquaticexercisefor

musculoskeletalconditions:ameta-analysis.ArchPhysMed Rehabil.2014;95:1776–86.

16.AmbrosiniAB,BrentanoMA,CoertjensM,KruelLFM.The effectsofstrengthtraininginhydrogymnasticsfor middle-agewomen.IntJAquatResEduc.2010;4:153–62. 17.BentoPCB,PereiraG,UgrinowitschC,RodackiALF.Theeffects

ofawater-basedexerciseprogramonstrengthan functionalityofolderadults.JAgingPhysAct.2012;20: 469–84.

18.BatterhamSI,HeywoodS,KeatingJL.Systematicreviewand meta-analysiscomparinglandandaquaticexercisefor peoplewithhiporkneearthritisonfunction,mobilityand otherhealthoutcomes.BMCMusculoskeletDisord. 2011;12:123.

19.ZhangW,NukiG,MoskowitzRW,AbramsonRD,AltmanNK, ArdenS,etal.OARSIrecommendationsforthemanagement ofhipandkneeosteoarthritis.PartIII:Changesinevidence followingsystematiccumulativeupdateofresearch publishedthroughJanuary2009.OsteoarthrCartil. 2010;18:476–99.

20.PedroT,ApV,DelphiT.PEDroscale.1999.Availableat:

http://www.pedro.org.au/portuguese/downloads/pedro-scale

[acessedon15.07.15].

21.ArnoldCM,FaulknerRA.Theeffectofaquaticexerciseand educationonloweringfallriskinolderadultswithhip osteoarthritis.JAgingPhysAct.2010;18:245–60.

22.HaleLA,WatersD,HerbisonP.Arandomizedcontrolledtrial toinvestigatetheeffectsofwater-basedexercisetoimprove fallsriskandphysicalfunctioninolderadultswith

lower-extremityosteoarthritis.ArchPhysMedRehabil. 2012;93:27–34.

23.LimJ-Y,TchaiE,JangS-N.Effectivenessofaquaticexercisefor obesepatientswithkneeosteoarthritis:arandomized controlledtrial.Pm&R.2010;2:723–31.

24.LundH,WeileU,ChristensenR,RostockB,DowneyA,Bartels EM,etal.Arandomizedcontrolledtrialofaquaticand land-basedexerciseinpatientswithkneeosteoarthritis.J RehabilMed.2008;40:137–44.

25.SilvaLE,ValimV,PessanhaAPC,OliveiraLM,MyamotoS, JonesA,etal.Hydrotherapyversusconventionalland-based exerciseforthemanagementofpatientswithosteoarthritis oftheknee:arandomizedclinicaltrial.PhysTher.

2008;88:12–21.

26.WyattFB,MilamS,ManskeRC,DeereR.Theeffectsofaquatic andtraditionalexerciseprogramsonpersonswithknee osteoarthritis.JStrengthCondRes.2001;15:337–40. 27.WangTJ,LeeSC,LiangSY,TungHH,WuSFV,LinYP.

Comparingtheefficacyofaquaticexercisesandland-based exercisesforpatientswithkneeosteoarthritis.JClinNurs. 2011;20:2609–22.

28.WallisJA,WebsterKE,LevingerP,FongC,TaylorNF.A pre-operativegrouprehabilitationprogrammeprovided limitedbenefitforpeoplewithseverehipandknee osteoarthritis.DisabilRehabil.2014;36:2085–90.

29.BresselE,WingJE,MillerAI,DolnyDG.High-intensityinterval trainingonanaquatictreadmillinadultswithosteoarthritis: effectonpain,balance,function,andmobility.JStrength CondRes.2014;28:2088–96.

30.WangT-J,BelzaB,ThompsonFE,WhitneyJD,BennettK. Effectsofaquaticexerciseonflexibility,strengthandaerobic fitnessinadultswithosteoarthritisofthehiporknee.JAdv Nurs.2007;57:141–52.

31.FiskenAL,WatersDL,HingWA,SteeleM,KeoghJW. Comparativeeffectsof2aquaexerciseprogramsonphysical function,balance,andperceivedqualityoflifeinolderadults withosteoarthritis.JGeriatrPhysTher.2015;38:17–27. 32.McAlindonTE,CooperC,KirwanJR,DieppePa.Kneepainand

disabilityinthecommunity.BrJRheumatol.1992;31:189–92. 33.HallMC,MockettSP,DohertyM.Relativeimpactof

radiographicosteoarthritisandpainonquadricepsstrength, proprioception,staticposturalswayandlowerlimbfunction. AnnRheumDis.2006;65:865–70.

34.PangJ,CaoY,ZhengY,GaoN,WangX,ChenB,etal.Influence ofpainseverityonhealth-relatedqualityoflifeinChinese kneeosteoarthritispatients.IntJClinExpMed.2015;8:4472–9. 35.TerweeCB,vanderSlikkeRMa,vanLummelRC,BeninkRJ,

MeijersWGH,deVetHCW.Self-reportedphysicalfunctioning wasmoreinfluencedbypainthanperformance-based physicalfunctioninginknee-osteoarthritispatients.JClin Epidemiol.2006;59:724–31.

36.RoperJ,TillmanMD,BresselE.Aquatictreadmillexercise improvesgaitmechanicsandmobilityforindividualswith unilateralkneeosteoarthritis.JGenInternMed.2012;27:691. 37.TsourlouT,BenikA,DiplaK,ZafeiridisA,KellisS.Theeffects

ofatwenty-fourweekaquatictrainingprogramonmuscular strengthperformanceinhealthyelderlywomen.JStrength CondRes.2006;20:811.

38.SuomiR,LindauerS.Effectivenessofarthritisfoundation aquaticprogramonstrengthandrangeofmotioninwomen witharthritis.JAgingPhysAct.1997;5:341–51.

39.NormanK,StobäusN,GonzalezMC,SchulzkeJ-D,PirlichM. Handgripstrength:outcomepredictorandmarkerof nutritionalstatus.ClinNutr.2011;30:135–42.

(13)

542

41.BentoPCB,RodackiALF.Musclefunctioninagedwomenin responsetoawater-basedexercisesprogramandprogressive resistancetraining.GeriatrGerontolInt.2015;15:1193–2000. 42.SuomiR,CollierD.Effectsofarthritisexerciseprogramson

functionalfitnessandperceivedactivitiesofdailyliving measuresinolderadultswitharthritis.ArchPhysMed Rehabil.2003;84:1589–94.

43.JordanKM,ArdenNK,DohertyM,BannwarthB,BijlsmaJWJ, DieppeP,etal.EULARRecommendations2003:anevidence basedapproachtothemanagementofkneeosteoarthritis: ReportofaTaskForceoftheStandingCommitteefor InternationalClinicalStudiesIncludingTherapeuticTrials (ESCISIT).AnnRheumDis.2003;62:1145–55.

44.BartelsElseM,LundH,HagenKåreB,DagfinrudH, ChristensenR,Danneskiold-SamsøeB.Aquaticexercisefor

thetreatmentofkneeandhiposteoarthritis.Cochrane DatabaseSystRev.2007:CD005523.

45.RahmannAE.Exerciseforpeoplewithhiporknee osteoarthritis:acomparisonofland-basedandaquatic interventions.OpenAccessJSportMed.2010;1:123–35. 46.HazellT,KennoK,JakobiJ.Functionalbenefitofpower

trainingforolderadults.JAgingPhysAct.2007;15: 349–59.

47.BarryBK,CarsonRG.Theconsequencesofresistancetraining formovementcontrolinolderadults.JGerontolABiolSci MedSci.2004;59:730–54.